CLINICAL PRACTICE
Randomized controlled trial of a web-based Acceptance and Commitment Therapy (ACT) program to promote mental health in university students
Shelley Viskovich,
Kenneth Ian Pakenham,
Corresponding Author
Shelley Viskovich
Doctor of Philosophy, School of Psychology, University of Queensland, Brisbane, Queensland, Australia
Correspondence Dr Shelley Viskovich, School of Psychology, University of Queensland, St Lucia, Brisbane, QLD 4072, Australia. Email [email protected]
Search for more papers by this authorKenneth Ian Pakenham
Professor of Clinical and Health Psychology, School of Psychology, University of Queensland, Brisbane, Queensland, Australia
Search for more papers by this authorShelley Viskovich,
Kenneth Ian Pakenham,
Corresponding Author
Shelley Viskovich
Doctor of Philosophy, School of Psychology, University of Queensland, Brisbane, Queensland, Australia
Correspondence Dr Shelley Viskovich, School of Psychology, University of Queensland, St Lucia, Brisbane, QLD 4072, Australia. Email [email protected]
Search for more papers by this authorKenneth Ian Pakenham
Professor of Clinical and Health Psychology, School of Psychology, University of Queensland, Brisbane, Queensland, Australia
Search for more papers by this authorAbstract
Objective
This study evaluated a 4-week web-based Acceptance and Commitment Therapy (ACT) mental health promotion intervention for university students.
Method
Participants were randomized to intervention (n = 596) or waitlist control (n = 566). Assessment of primary outcomes (depression, anxiety, stress, well-being, self-compassion, life satisfaction, and academic performance) and ACT processes (acceptance, cognitive fusion, education values, valued living, and present moment awareness) occurred at pre- and post-intervention and 12-week follow-up for intervention participants, and the same pre–post interval for waitlist control participants.
Results
Analyses showed significant improvements from pre- to post-intervention compared with waitlist control on all primary outcomes and ACT processes. All intervention gains were maintained at follow-up. Improvements on all primary outcomes were mediated by three or more ACT processes in both samples. Intervention effects were consistent across both sample groupings.
Conclusion
Findings provide support for a web-based ACT mental health promotion intervention for university students.
REFERENCES
- A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of Acceptance and Commitment Therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. https://doi.org/10.1159/000365764
- Amstadter, A. B., Broman-Fulks, J., Zinzow, H., Ruggiero, K. J., & Cercone, J. (2009). Internet-based interventions for traumatic stress-related mental health problems: A review and suggestion for future research. Clinical Psychology Review, 29(5), 410–420. https://doi.org/10.1016/j.cpr.2009.04.001
- Andersson, G., & Cuijpers, P. (2009). Internet-based and other computerized psychological treatments for adult depression: A meta-analysis. Cognitive Behaviour Therapy, 38(4), 196–205. https://doi.org/10.1080/16506070903318960
- Andrews, B., & Wilding, J. M. (2004). The relation of depression and anxiety to life-stress and achievement in students. British Journal of Psychology, 95, 509–521. https://doi.org/10.1348/0007126042369802
- Beintner, I., Jacobi, C., & Taylor, C. B. (2012). Effects of an internet-based prevention programme for eating disorders in the USA and Germany - A meta-analytic review: Internet-based prevention for ED. European Eating Disorders Review, 20(1), 1–8. https://doi.org/10.1002/erv.1130
- Bewick, B., Koutsopoulou, G., Miles, J., Slaa, E., & Barkham, M. (2010). Changes in undergraduate students' psychological well-being as they progress through university. Studies in Higher Education, 35(6), 633–645. https://doi.org/10.1080/03075070903216643
- Biglan, A., Hayes, S. C., & Pistorello, J. (2008). Acceptance and commitment: Implications for prevention science. Prevention Science, 9(3), 139–152. https://doi.org/10.1007/s11121-008-0099-4
- Blackledge, J. T., Ciarrochi, J., & Bailey, A. (n.d.). Personal Values Questionnaire II. Retrieved from https://contextualscience.org/personal_values_questionnaire. Accessed 19 August 2015.
- Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S. M., & Olfson, M. (2008). Mental health of college students and their non-college-attending peers: Results from the National Epidemiologic Study on alcohol and related conditions. Archives of General Psychiatry, 65(12), 1429–1437. https://doi.org/10.1001/archpsyc.65.12.1429
- Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., … Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–688. https://doi.org/10.1016/j.beth.2011.03.007
- Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
10.1191/1478088706qp063oa Google Scholar
- Brooke, J. (1996). SUS - A quick and dirty usability scale. Retrieved from https://www.usability.gov/how-to-and-tools/methods/system-usability-scale.html. Accessed 13 August 2015.
- Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. https://doi.org/10.1037/0022-3514.84.4.822
- Chase, J. A., Houmanfar, R., Hayes, S. C., Ward, T. A., Vilardaga, J. P., & Follette, V. (2013). Values are not just goals: Online ACT-based values training adds to goal setting in improving undergraduate college student performance. Journal of Contextual Behavioral Science, 2(3-4), 79–84. https://doi.org/10.1016/j.jcbs.2013.08.002
10.1016/j.jcbs.2013.08.002 Google Scholar
- Christensen, H. (2004). Delivering interventions for depression by using the internet: Randomised controlled trial. BMJ, 328(7434), https://doi.org/10.1136/bmj.37945.566632.EE. 265-0.
10.1136/bmj.37945.566632.EE Google Scholar
- Cotton Bronk, K., Hill, P. L., Lapsley, D. K., Talib, T. L., & Finch, H. (2009). Purpose, hope, and life satisfaction in three age groups. The Journal of Positive Psychology, 4(6), 500–510. https://doi.org/10.1080/17439760903271439
- Craske, M. G. (2012). Transdiagnostic treatment for anxiety and depression. Depression and Anxiety, 29(9), 749–753. https://doi.org/10.1002/da.21992
- Croom, K., Staiano-Coico, L., Lesser, M. L., Lewis, D. K., Reyna, V. F., Marchell, T. C., … Ives, S. (2015). The glass is half full: Evidence for efficacy of alcohol-wise at one university but not the other. Journal of Health Communication, 20(6), 627–638. https://doi.org/10.1080/10810730.2015.1012239
- Cuijpers, P., van Straten, A., & Andersson, G. (2008). Internet-administered cognitive behavior therapy for health problems: A systematic review. Journal of Behavioral Medicine, 31(2), 169–177. https://doi.org/10.1007/s10865-007-9144-1
- Diener, E., Emmons, R. A., Larsen, R. J., & Griffin, S. (1985). The satisfaction with life scale. Journal of Personality Assessment, 49(1), 71–75. https://doi.org/10.1207/s15327752jpa4901_13
- Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health care in a university student population. Medical Care, 45(7), 594–601. https://doi.org/10.1097/mlr.0b013e31803bb4c1
- Eisenberg, D., Gollust, S. E., Golberstein, E., & Hefner, J. L. (2007). Prevalence and correlates of depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry, 77(4), 534–542. https://doi.org/10.1037/0002-9432.77.4.534
- Eustis, E. H., Hayes-Skelton, S. A., Orsillo, S. M., & Roemer, L. (2018). Surviving and thriving during stress: A randomized clinical trial comparing a brief web-based therapist-assisted acceptance-based behavioral intervention versus waitlist control for college students. Behavior Therapy, 49(6), 889–903. https://doi.org/10.1016/j.beth.2018.05.009.
- Farrand, P., & Woodford, J. (2013). Impact of support on the effectiveness of written cognitive behavioural self-help: A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 33(1), 182–195. https://doi.org/10.1016/j.cpr.2012.11.001
- French, K., Golijani-Moghaddam, N., & Schröder, T. (2017). What is the evidence for the efficacy of self-help acceptance and commitment therapy? A systematic review and meta-analysis. Journal of Contextual Behavioral Science, 6(4), 360–374. https://doi.org/10.1016/j.jcbs.2017.08.002
- Gaetano, J. (2019). Welch’s t-test for comparing two independent groups: An Excel calculator (1.0.1). https://ideospectus.com/2018/10/22/welchs-t-test-calculator-v-1-0/
- Gallagher, R. P. (2012). Thirty years of the national survey of counseling center directors: A personal account. Journal of College Student Psychotherapy, 26(3), 172–184. https://doi.org/10.1080/87568225.2012.685852
10.1080/87568225.2012.685852 Google Scholar
- Gallagher, R. P. (2014). National survey of college counseling centers 2013. Section one: 4-year directors. Pittsburgh, PA: University of Pittsburgh.
- Gillanders, D. T., Bolderston, H., Bond, F. W., Dempster, M., Flaxman, P. E., Campbell, L., … Remington, B. (2014). The development and initial validation of the cognitive fusion questionnaire. Behavior Therapy, 45, 83–101. https://doi.org/10.1016/j.beth.2013.09.001
- Graham, John W., Olchowski, Allison E., & Gilreath, Tamika D. (2007). How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevention Science, 8(3), 206–213. https://doi.org/10.1007/s11121-007-0070-9.
- Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy as a unified model of behavior change. The Counseling Psychologist, 40(7), 976–1002. https://doi.org/10.1177/0011000012460836
- Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy. An experiential approach to behavior change ( 2nd ed.). New York, NY: The Guildford Press.
- Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19. https://doi.org/10.1037/0022-006X.59.1.12
- Keyes, L. M. (2009). Brief description of the mental health continuum short form (MHC-SF). Retrieved from http://www.sociology.emory.edu/ckeyes/. Accessed 14 August 2015.
- Kim, J. E., Saw, A., & Zane, N. (2015). The influence of psychological symptoms on mental health literacy of college students. American Journal of Orthopsychiatry, 85(6), 620–630. https://doi.org/10.1037/ort0000074
- Lappalainen, P., Granlund, A., Siltanen, S., Ahonen, S., Vitikainen, M., Tolvanen, A., & Lappalainen, R. (2014). ACT internet-based vs face-to-face? A randomized controlled trial of two ways to deliver acceptance and commitment therapy for depressive symptoms: An 18-month follow-up. Behaviour Research and Therapy, 61, 43–54. https://doi.org/10.1016/j.brat.2014.07.006
- Levin, M. E., Hayes, S. C., Pistorello, J., & Seeley, J. R. (2016). Web-based self-help for preventing mental health problems in universities: Comparing acceptance and commitment training to mental health education. Journal of Clinical Psychology, 72(3), 207–225. https://doi.org/10.1002/jclp.22254
- Levin, M. E., Haeger, J. A., Pierce, B. G., & Twohig, M. P. (2016). Web-based acceptance and commitment therapy for mental health problems in college students: A randomized controlled trial. Behavior Modification, 41(1), 141–162. https://doi.org/10.1177/0145445516659645
- Levin, M. E., Pistorello, J., Hayes, S. C., Seeley, J. R., & Levin, C. (2015). Feasibility of an acceptance and commitment therapy adjunctive web-based program for counseling centers. Journal of Counseling Psychology, 62(3), 529–536. https://doi.org/10.1037/cou0000083
- Levin, M. E., Pistorello, J., Seeley, J. R., & Hayes, S. C. (2014). Feasibility of a prototype web-based acceptance and commitment therapy prevention program for college students. Journal of American College Health, 62(1), 20–30. https://doi.org/10.1080/07448481.2013.843533
- Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck depression and anxiety inventories. Behaviour Research and Therapy, 33(3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U
- McCracken, L. M., DaSilva, P., Skillicorn, B., & Doherty, R. (2014). The Cognitive Fusion Questionnaire: A preliminary study of psychometric properties and prediction of functioning in chronic pain. The Clinical Journal of Pain, 30(10), 894–901. https://doi.org/10.1097/AJP.0000000000000047
- Moher, D., Hopewell, S., Schulz, K. F., Montori, V., Gøtzsche, P. C., Devereaux, P. J., … Altman, D. G. (2010). CONSORT 2010 explanation and elaboration: Updated guidelines for reporting parallel group randomised trials. Journal of Clinical Epidemiology, 63(8), e1–e37. https://doi.org/10.1016/j.jclinepi.2010.03.004
- Montoya, A. K., & Hayes, A. F. (2017). Two-condition within-participant statistical mediation analysis: A path-analytic framework. Psychological Methods, 22(1), 6–27. https://doi.org/10.1037/met0000086.
- Muto, T., Hayes, S. C., & Jeffcoat, T. (2011). The effectiveness of acceptance and commitment therapy bibliotherapy for enhancing the psychological health of Japanese college students living abroad. Behavior Therapy, 42(2), 323–335. https://doi.org/10.1016/j.beth.2010.08.009
- Neff, K. D., Hsieh, Y. -P., & Dejitterat, K. (2005). Self-compassion, achievement goals, and coping with academic failure. Self and Identity, 4(3), 263–287. https://doi.org/10.1080/13576500444000317
- Pakenham, K. I. (2017). Training in acceptance and commitment therapy fosters self-care in clinical psychology trainees. Clinical Psychologist, 21(3), 186–194. https://doi.org/10.1111/cp.12062.
- Paliliunas, D., Belisle, J., & Dixon, M. R. (2018). A randomized control trial to evaluate the use of acceptance and commitment therapy (ACT) to increase academic performance and psychological flexibility in graduate students. Behavior Analysis in Practice, 11(3), 241–253. https://doi.org/10.1007/s40617-018-0252-x.
- Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36(4), 717–731. https://doi.org/10.3758/BF03206553
- Raes, F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011). Construction and factorial validation of a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy, 18, 250–255. https://doi.org/10.1002/cpp.702
- Regehr, C., Glancy, D., & Pitts, A. (2013). Interventions to reduce stress in university students: A review and meta-analysis. Journal of Affective Disorders, 148(1), 1–11. https://doi.org/10.1016/j.jad.2012.11.026
- Reinwand, D. A., Crutzen, R., Elfeddali, I., Schneider, F., Schulz, D. N., Stanczyk, N. E., … de Vries, H. (2015). Impact of educational level on study attrition and evaluation of web-based computer-tailored interventions: Results from seven randomized controlled trials. Journal of Medical Internet Research, 17(10):e228. https://doi.org/10.2196/jmir.4941
- Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: A systematic review and meta-analysis. Clinical Psychology Review, 32(4), 329–342. https://doi.org/10.1016/j.cpr.2012.02.004
- Rickwood, D. J., Deane, F. P., & Wilson, C. J. (2007). When and how do young people seek professional help for mental health problems? The Medical Journal of Australia, 187(3 Suppl), 35–39. https://doi.org/10.5172/jamh.4.3.218
10.5694/j.1326-5377.2007.tb01334.x Google Scholar
- Rubin, D. B. (1996). Multiple imputation after 18+ years. Journal of the American Statistical Association, 91(434), 473–489. https://doi.org/10.2307/2291635
- Ruiz, F. J. (2012). Acceptance and commitment therapy versus traditional cognitive behavioral therapy: A systematic review and meta-analysis of current empirical evidence. International Journal of Psychology and Psychological Therapy. 12(2), 333–357. Retrieved from. https://www.ijpsy.com/volumen312/num333/334.html
- Ryan, M. L., Shochet, I. M., & Stallman, H. M. (2010). Universal online interventions might engage psychologically distressed university students who are unlikely to seek formal help. Advances in Mental Health, 9(1), 73–83. https://doi.org/10.5172/jamh.9.1.73
10.5172/jamh.9.1.73 Google Scholar
- Räsänen, P., Lappalainen, P., Muotka, J., Tolvanen, A., & Lappalainen, R. (2016). An online guided ACT intervention for enhancing the psychological wellbeing of university students: A randomized controlled clinical trial. Behaviour Research and Therapy, 78(2016), 30–42. https://doi.org/0.1016/j.brat.2016.01.001
- Sauro, J. (2011). Measuring Usability with the System Usability Scale (SUS). Retrieved from https://measuringu.com/sus/d. Accessed 25 January, 2017.
- Scheffer, J. (2002). Dealing with missing data. Research Letters in the Information and Mathematical Science, 3, 153–160. Retrieved from. www.scirp.org
- Stafford-Brown, J., & Pakenham, K. I. (2012). The effectiveness of an ACT informed intervention for managing stress and improving therapist qualities in clinical psychology trainees. Journal of Clinical Psychology, 68(6), 592–613. https://doi.org/10.1002/jclp.21844
- Stallman, H. M., & Kavanagh, D. J. (2018). Development of an internet intervention to promote wellbeing in college students. Australian Psychologist, 53(1), 60–67. https://doi.org/10.1111/ap.12246.
- Stallman, H. M., & Shochet, I. (2009). Prevalence of mental health problems in Australian university health services. Australian Psychologist, 44(2), 122–127. https://doi.org/10.1080/00050060902733727
- Stallman, H. M. (2010). Psychological distress in university students: A comparison with general population data. Australian Psychologist, 45(4), 249–257. https://doi.org/10.1080/00050067.2010.482109
- Stallman, H. M. (2012). University counselling services in Australia and New Zealand: Activities, changes, and challenges. Australian Psychologist, 47(4), 249–253. https://doi.org/10.1111/j.1742-9544.2011.00023.x
- Trompetter, H. R., Bohlmeijer, E. T., Veehof, M. M., & Schreurs, K. M. G. (2015). Internet-based guided self-help intervention for chronic pain based on acceptance and commitment therapy: A randomized controlled trial. Journal of Behavioral Medicine, 38(1), 66–80. https://doi.org/10.1007/s10865-014-9579-0
- Trompetter, H. R., ten Klooster, P. M., Schreurs, K. M. G., Fledderus, M., Westerhof, G. J., & Bohlmeijer, E. T. (2013). Measuring values and committed action with the Engaged Living Scale (ELS): Psychometric evaluation in a nonclinical sample and a chronic pain sample. Psychological Assessment, 25(4), 1235–1246. https://doi.org/10.1037/a0033813
- Vaez, M., & Laflamme, L. (2008). Experienced stress, psychological symptoms, self-rated health and academic achievement: A longitudinal study of Swedish university students. Social Behavior and Personality: An International Journal, 36(2), 183–196. https://doi.org/10.2224/sbp.2008.36.2.183
- Viskovich, S., & Pakenham, K. I. (2018). Pilot evaluation of a web-based acceptance and commitment therapy program to promote mental health skills in university students. Journal of Clinical Psychology, 74(12), 2047–2069. https://doi.org/10.1002/jclp.22656
